Healthcare Provider Details

I. General information

NPI: 1952962763
Provider Name (Legal Business Name): MARTELL EYECARE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/23/2019
Last Update Date: 01/01/2020
Certification Date: 01/01/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

703 THIRD STREET
MARATHON WI
54448
US

IV. Provider business mailing address

322 ROSS AVE
WAUSAU WI
54403
US

V. Phone/Fax

Practice location:
  • Phone: 715-870-1454
  • Fax:
Mailing address:
  • Phone: 715-870-1454
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code332H00000X
TaxonomyEyewear Supplier
License Number
License Number State

VIII. Authorized Official

Name: KEN MARTELL
Title or Position: OWNER
Credential: OD
Phone: 715-870-1454